Director of Self Management Education
Qualifications:
Candidate should be a nurse or Social Worker who has management experience and MDS/PPS knowledge. Patient and family education, and patient advocacy is a plus.
Duties:
Clinical Compliance
- Monitors admissions process to ensure that…
- All medications have been sent to the pharmacy in a timely manner
- Diet has been communicated to the dietary department
- Nurses, CNAs, Rehab are aware of new admissions and has greeted the new patient in a timely manner
- Monitors clinical documentation daily
- Ensure that nurses are documenting based on the skilled need(s)
- Ensure that careplans are updated according to clinical needs
- Ensures compliance with the Clinical Systems for all Post Acute patients
- Ensures compliance with consents, as appropriate
PPS Management
- Manages PPS process for Post Acute patients
- Ensures that the Post Acute patients receive nursing care in order to be successful when they are discharged to home
Liaison
- Work directly with the Admissions Department to understand the clinical needs of pending admissions
- Communicate with internal Department Heads about the needs of upcoming admissions
- Communicate with Therapy Director on daily basis
- Ensure that therapy goals are incorporated in nursing staff practice and nursing restorative program are implemented
Transition Duties
- Meets with all admissions to provide a facility orientation. First meeting should occur within 1 hour of admission
- Conducts follow up meeting with patients and their families after 24 hours to ensure that all needs are met
- Identifies any problems/concerns and follows up with those concerns until resolved.
- Spends TLC time with high intensity patients and families
- Identifies all patients scheduled for discharge and meets with them 3-4 days pre discharge
- Develops plan of care with pt and charge nurse
- Identify and develop pt education needs
- Monitor progress of pt education
- Ensures that transition plans are in place for discharge, including Transition U and medication reconciliation process
- Provides coaching with patient and family to increase the likelihood of their success at discharge
- Assesses their understanding of why they were hospitalized
- Assesses their recognition of Red Flag systems that could have avoided the hospitalization
- Interacts with patient and family to ensure that they recognize Red Flags that can be avoided
- Subsequent hospital readmissions
- Interacts with patient and family to ensure that they understand how to communicate with their healthcare practitioner
- Interacts with patient and family to reconcile their medications prior to discharge
- Conducts the 24 hours admission survey and the discharge satisfaction survey
- Contacts patient and family within 24 hours of discharge to ensure smooth transition home.
- Follows up with patients around day 20 post discharge to ensure that the transition was smooth and to determine if they need additional post acute services.